1) Inspection & palpation of the perineum 2) Per-rectal ...

Ano-rectal examination

1) Inspection & palpation of the perineum

2) Per-rectal examination (PR)

3) Anoscopy

Localization &Recording

Anal verge Dentate line

Privacy & Witness

Instruments

Patient’s position & Exposure

90

90-100

10cm

Inspection & Palpationof

the perineum

Inspection & Palpationof

the perineum

Per Rectal Examination(PR)

Umbilicus

100

4cm

Per Rectal Examination(PR)

Umbilicus

100

4cm

Per Rectal Examination(PR)

Anoscopy

Anoscopy

4cm

100

Umbilicus

Anoscopy

4cm

100

Umbilicus

The most common benign anal-rectal diseases

1-Hemorrhoids(piles)

2-Anal fissure

3-Anorectal abscess and

4-Fistula-in-ano

Hemorrhoids

• • EH: distal to dentate, covered

• by anoderm, PAIN &LUMP

• • IH: prox. to dentate, covered by

• mucosa, PAINLESS BLEEDING

• Combined hemorrhoids

• • PE: make sure to evaluate

• with straining, complete AR

• exam.

37

11

Ext. HemorrhoidsThrombosed

Ext. Hemorrhoids

1) Conservative management:bulking agents,NSAIDS,topical agents and

warm sitz baths

2) Less likely surgery: deroofing of the thrombosed external hemorrhoids

Treatment of External hemorrhoids

Internal Hemorrhoids: Grade

Degrees of internal hemorrhoids1- First degree : Bleeds, but does not prolapse.2- Second degree :protrudes with straining; reduces

spontaneously.3- Third degree : Spontaneous protrusion ; need

manual reduction.4- Fourth degree : Irreducible to manual reduction

(constantly outside)

Internal Hemorrhoids (cont.)

Diagnosis:• Painless anorectal

• bleeding is the

main complaint in the 1st.

degree

• Prolapsing mass is the

• main feature of the 2nd 3rd

• and the 4th.degrees

• P.R and proctoscopy are mandatory to exclude secondary piles due to carcinoma.

Treatment of Internal hemorrhoids

1) –Consevative management:It is reserved for first degree in the form of bulking agents, topical agents and vasotonic agents

(diosamine).2) - Sclerotherapy (1 – 2 ml sclerosing agent in

the submucosal space proximal to the hemorrhoids)

3) – Infrared photocoagulation4 )- Banding

Treatment of hemorrhoid (cont.)

5 )-Traditional hemorrhoidectomy:

- Open technique of Milligan.

-Closed technique of Ferguson

6 ) - Hemorrhoidectomy using Ligasure, Harmonic scapel

7 )- Stapled Circular Hemorrhoidectomy.